Provider Demographics
NPI:1407631435
Name:WILSON, ASHLEY SHULL
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:SHULL
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 COTTAGE RD
Mailing Address - Street 2:
Mailing Address - City:BLACKSTONE
Mailing Address - State:VA
Mailing Address - Zip Code:23824-3447
Mailing Address - Country:US
Mailing Address - Phone:540-292-5693
Mailing Address - Fax:
Practice Address - Street 1:833 BUFFALO ST STE 200
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-1111
Practice Address - Country:US
Practice Address - Phone:434-392-8177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024187957363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily